Systems and methods for a medical clip applier

ABSTRACT

Certain aspects relate to systems and techniques for articulating medical instruments. In one aspect, the instrument includes a wrist having at least one degree of freedom of movement, and an end effector coupled to the wrist. The end effector can include a cartridge for delivering a plurality of clips to tissue. The wrist may include one or more cables capable of moving an actuator with one degree of freedom of movement within the end effector to advance one or more clips through the end effector.

CROSS-REFERENCE TO RELATED APPLICATION(S)

This application claims the benefit of U.S. Provisional Application No.62/867,452, filed Jun. 27, 2019, which is hereby incorporated byreference in its entirety.

TECHNICAL FIELD

The systems and methods disclosed herein are directed to medicalinstruments, and more particularly to clip appliers.

BACKGROUND

Medical clips can be used in a variety of different medical procedures,including, for example, laparoscopic procedures in which the medicalclips may be used to ligate and/or seal tissue to stop bleeding. The useof clips can reliably engage tissue and be retained and secured inplace. The use of clips to ligate tissue can advantageous as they can befaster than the use of sutures to ligate tissue.

SUMMARY

The systems, methods and devices of this disclosure each have severalinnovative aspects, no single one of which is solely responsible for thedesirable attributes disclosed herein.

In a first aspect, a robotically-controlled surgical instrument includesa wrist extending from the distal end of the elongate shaft, the wristproviding at least one degree of freedom of movement, and an endeffector extending from the wrist and moveable with the wrist, the endeffector comprising a cartridge for delivering a plurality of clips insuccession without reloading.

The robotically-controlled surgical instrument may further include oneor more of the following features in any combination: (a) wherein theplurality of clips includes at least four clips; (b) wherein theplurality of clips are nested with each other within the cartridge; (c)wherein a length of the plurality of clips is at least 50% less than ifthe plurality of clips were each laid end to end; (d) wherein first openends of the plurality of clips are positioned within the first track;(e) wherein the shaft is coupled to a robotic arm; (f) wherein each ofthe plurality of clips includes a first arm with a distal end and asecond arm with a distal end, the first and second arms connectedtogether at their respective proximal ends; (g) wherein the cartridgeincludes a first track and a second track, and wherein the distal end ofeach of the first arms is positioned within the first track and thedistal end of each of the second arms is positioned within the secondtrack to hold each of the plurality of clips in an open position; (h)wherein when each of the clips are expelled from the cartridge, thefirst and second arm of each of the clips move towards each other to aclosed position; (i) wherein in the closed position the distal end ofthe first arm is intermeshed with the distal end of the second arm; (j)wherein each of the plurality of clips are configured to be stored inthe cartridge in the open position and be closed onto tissue in theclosed position, wherein the distal end of the first arm and the distalend of the second arm are separated from each other in the openposition, wherein the distal end of the first arm and the distal end ofthe second arm are intermeshed with each other; (k) wherein the distalend of the first arm includes a tab; (l) wherein the distal end of thesecond arm includes a loop that is larger than the tab of the first arm;(m) wherein the tab of the first arm includes a loop that is smallerthan the loop of the second arm; (n) wherein the first and second armsconnect together at their respective proximal ends by a loop; (o)wherein the first and second arms connect together at their respectiveproximal ends by a plurality of loops; and/or (p) wherein the elongateshaft is capable of movement in one degree of freedom.

In another aspect, a surgical instrument includes an elongate shaftextending between a proximal end and a distal end, a wrist extendingfrom the distal end of the elongate shaft, and an end effector extendingfrom the wrist. The wrist can include one or more cables capable ofmoving an actuator with one degree of freedom of movement within the endeffector to advance one or more clips through the end effector. The oneor more clips can be capable of being both delivered and automaticallyclipped by the one degree of freedom movement of the actuator.

The surgical instrument may further include one or more of the followingfeatures in any combination: (a) wherein the one or more clips arereceived in a cartridge; (b) wherein the one or more clips move along atrack within the cartridge; (c) wherein the track is configured toengage with a distal end of each of the one or more clips to hold theeach of the one or more clips in an open position prior to delivery; (d)wherein the actuator advances the one or more clips along the track withthe cartridge; and/or (e) wherein the elongate shaft is capable ofmovement in one degree of freedom.

In another aspect, a surgical instrument for securing tissue includes acartridge including one or more clips, the one or more clips eachincludes a first arm including a first distal portion and a second armincluding a second distal portion. The one or more clips can include afirst configuration in an open position and a second configuration in aclosed position. The first distal portion can be capable of intermeshingwith the second distal portion when the clip is in the closed position.The first arm may include a single strut and the second arm may includea pair of struts, the single strut of the first arm capable of movingbetween pair of struts of the second arm.

In yet another aspect, a surgical clip configured to close on tissueincludes a first arm including a first strut, and a second arm includinga second strut and a third strut. A distal end of the first arm canintermesh with a distal end of the second arm. A proximal end of thefirst arm and a proximal end of the second arm are joined to form avertex, the vertex forming a torsion spring.

The surgical clip configured to close on tissue may further include oneor more of the following features in any combination: (a) wherein thedistal end of the first strut forms a loop; (b) wherein the distal endsof the second strut and third strut form a loop that is larger than theloop of the first strut; (c) wherein the larger loop of the second strutand the third strut receives the smaller loop of the first strut whenthe clip is in a closed position; (d) wherein the first strut isreceived between the second strut and the third strut when the clip isin a closed position; and/or (e) wherein the torsion spring comprisesone or more loops.

BRIEF DESCRIPTION OF THE DRAWINGS

The disclosed aspects will hereinafter be described in conjunction withthe appended drawings, provided to illustrate and not to limit thedisclosed aspects, wherein like designations denote like elements.

FIG. 1 illustrates an embodiment of a cart-based robotic system arrangedfor diagnostic and/or therapeutic bronchoscopy.

FIG. 2 depicts further aspects of the robotic system of FIG. 1.

FIG. 3 illustrates an embodiment of the robotic system of FIG. 1arranged for ureteroscopy.

FIG. 4 illustrates an embodiment of the robotic system of FIG. 1arranged for a vascular procedure.

FIG. 5 illustrates an embodiment of a table-based robotic systemarranged for a bronchoscopic procedure.

FIG. 6 provides an alternative view of the robotic system of FIG. 5.

FIG. 7 illustrates an example system configured to stow robotic arm(s).

FIG. 8 illustrates an embodiment of a table-based robotic systemconfigured for a ureteroscopic procedure.

FIG. 9 illustrates an embodiment of a table-based robotic systemconfigured for a laparoscopic procedure.

FIG. 10 illustrates an embodiment of the table-based robotic system ofFIGS. 5-9 with pitch or tilt adjustment.

FIG. 11 provides a detailed illustration of the interface between thetable and the column of the table-based robotic system of FIGS. 5-10.

FIG. 12 illustrates an alternative embodiment of a table-based roboticsystem.

FIG. 13 illustrates an end view of the table-based robotic system ofFIG. 12.

FIG. 14 illustrates an end view of a table-based robotic system withrobotic arms attached thereto.

FIG. 15 illustrates an exemplary instrument driver.

FIG. 16 illustrates an exemplary medical instrument with a pairedinstrument driver.

FIG. 17 illustrates an alternative design for an instrument driver andinstrument where the axes of the drive units are parallel to the axis ofthe elongated shaft of the instrument.

FIG. 18 illustrates an instrument having an instrument-based insertionarchitecture.

FIG. 19 illustrates an exemplary controller.

FIG. 20 depicts a block diagram illustrating a localization system thatestimates a location of one or more elements of the robotic systems ofFIGS. 1-10, such as the location of the instrument of FIGS. 16-18, inaccordance to an example embodiment.

FIG. 21 illustrates an example embodiment of a medical instrument inaccordance with aspects of this disclosure.

FIG. 22A illustrates an example embodiment of a surgical clip in an openposition.

FIG. 22B illustrate the surgical clip of FIG. 22A in the closedposition.

FIG. 22C illustrates a side view of the surgical clip of FIGS. 22A and22B in an open position.

FIG. 22D illustrates a side view of the surgical clips of FIGS. 22A-22Cin a closed position.

FIG. 22E illustrates a side view of the surgical clips of FIGS. 22A-22Din a closed position.

FIG. 23 illustrates the surgical clip closed on a vessel.

FIG. 24A illustrates another example embodiment of a surgical clip in anopen position.

FIG. 24B illustrates the surgical clip of FIG. 24A in a closed position.

FIG. 25A illustrates a top perspective view of a clip applier orcartridge.

FIG. 25B illustrates a bottom perspective view of the clip applier orcartridge of FIG. 25A.

FIG. 25C illustrates a front perspective view of the clip applier orcartridge of FIGS. 25A-25B.

FIG. 26 illustrates a cartridge with the first and bottom platesremoved.

FIGS. 27A and 27B illustrate side views of the cartridge with thatincludes tracks for engagement with the clips.

FIGS. 28A and 28B illustrate the cartridge with the outer housingremoved.

DETAILED DESCRIPTION

1. Overview.

Aspects of the present disclosure may be integrated into arobotically-enabled medical system capable of performing a variety ofmedical procedures, including both minimally invasive, such aslaparoscopy, and non-invasive, such as endoscopy, procedures. Amongendoscopic procedures, the system may be capable of performingbronchoscopy, ureteroscopy, gastroscopy, etc.

In addition to performing the breadth of procedures, the system mayprovide additional benefits, such as enhanced imaging and guidance toassist the physician. Additionally, the system may provide the physicianwith the ability to perform the procedure from an ergonomic positionwithout the need for awkward arm motions and positions. Still further,the system may provide the physician with the ability to perform theprocedure with improved ease of use such that one or more of theinstruments of the system can be controlled by a single user.

Various embodiments will be described below in conjunction with thedrawings for purposes of illustration. It should be appreciated thatmany other implementations of the disclosed concepts are possible, andvarious advantages can be achieved with the disclosed implementations.Headings are included herein for reference and to aid in locatingvarious sections. These headings are not intended to limit the scope ofthe concepts described with respect thereto. Such concepts may haveapplicability throughout the entire specification.

A. Robotic System—Cart.

The robotically-enabled medical system may be configured in a variety ofways depending on the particular procedure. FIG. 1 illustrates anembodiment of a cart-based robotically-enabled system 10 arranged for adiagnostic and/or therapeutic bronchoscopy. During a bronchoscopy, thesystem 10 may comprise a cart 11 having one or more robotic arms 12 todeliver a medical instrument, such as a steerable endoscope 13, whichmay be a procedure-specific bronchoscope for bronchoscopy, to a naturalorifice access point (i.e., the mouth of the patient positioned on atable in the present example) to deliver diagnostic and/or therapeutictools. As shown, the cart 11 may be positioned proximate to thepatient's upper torso in order to provide access to the access point.Similarly, the robotic arms 12 may be actuated to position thebronchoscope relative to the access point. The arrangement in FIG. 1 mayalso be utilized when performing a gastro-intestinal (GI) procedure witha gastroscope, a specialized endoscope for GI procedures. FIG. 2 depictsan example embodiment of the cart in greater detail.

With continued reference to FIG. 1, once the cart 11 is properlypositioned, the robotic arms 12 may insert the steerable endoscope 13into the patient robotically, manually, or a combination thereof. Asshown, the steerable endoscope 13 may comprise at least two telescopingparts, such as an inner leader portion and an outer sheath portion, eachportion coupled to a separate instrument driver from the set ofinstrument drivers 28, each instrument driver coupled to the distal endof an individual robotic arm. This linear arrangement of the instrumentdrivers 28, which facilitates coaxially aligning the leader portion withthe sheath portion, creates a “virtual rail” 29 that may be repositionedin space by manipulating the one or more robotic arms 12 into differentangles and/or positions. The virtual rails described herein are depictedin the Figures using dashed lines, and accordingly the dashed lines donot depict any physical structure of the system. Translation of theinstrument drivers 28 along the virtual rail 29 telescopes the innerleader portion relative to the outer sheath portion or advances orretracts the endoscope 13 from the patient. The angle of the virtualrail 29 may be adjusted, translated, and pivoted based on clinicalapplication or physician preference. For example, in bronchoscopy, theangle and position of the virtual rail 29 as shown represents acompromise between providing physician access to the endoscope 13 whileminimizing friction that results from bending the endoscope 13 into thepatient's mouth.

The endoscope 13 may be directed down the patient's trachea and lungsafter insertion using precise commands from the robotic system untilreaching the target destination or operative site. In order to enhancenavigation through the patient's lung network and/or reach the desiredtarget, the endoscope 13 may be manipulated to telescopically extend theinner leader portion from the outer sheath portion to obtain enhancedarticulation and greater bend radius. The use of separate instrumentdrivers 28 also allows the leader portion and sheath portion to bedriven independently of each other.

For example, the endoscope 13 may be directed to deliver a biopsy needleto a target, such as, for example, a lesion or nodule within the lungsof a patient. The needle may be deployed down a working channel thatruns the length of the endoscope to obtain a tissue sample to beanalyzed by a pathologist. Depending on the pathology results,additional tools may be deployed down the working channel of theendoscope for additional biopsies. After identifying a nodule to bemalignant, the endoscope 13 may endoscopically deliver tools to resectthe potentially cancerous tissue. In some instances, diagnostic andtherapeutic treatments can be delivered in separate procedures. In thosecircumstances, the endoscope 13 may also be used to deliver a fiducialto “mark” the location of the target nodule as well. In other instances,diagnostic and therapeutic treatments may be delivered during the sameprocedure.

The system 10 may also include a movable tower 30, which may beconnected via support cables to the cart 11 to provide support forcontrols, electronics, fluidics, optics, sensors, and/or power to thecart 11. Placing such functionality in the tower 30 allows for a smallerform factor cart 11 that may be more easily adjusted and/orre-positioned by an operating physician and his/her staff. Additionally,the division of functionality between the cart/table and the supporttower 30 reduces operating room clutter and facilitates improvingclinical workflow. While the cart 11 may be positioned close to thepatient, the tower 30 may be stowed in a remote location to stay out ofthe way during a procedure.

In support of the robotic systems described above, the tower 30 mayinclude component(s) of a computer-based control system that storescomputer program instructions, for example, within a non-transitorycomputer-readable storage medium such as a persistent magnetic storagedrive, solid state drive, etc. The execution of those instructions,whether the execution occurs in the tower 30 or the cart 11, may controlthe entire system or sub-system(s) thereof. For example, when executedby a processor of the computer system, the instructions may cause thecomponents of the robotics system to actuate the relevant carriages andarm mounts, actuate the robotics arms, and control the medicalinstruments. For example, in response to receiving the control signal,the motors in the joints of the robotics arms may position the arms intoa certain posture.

The tower 30 may also include a pump, flow meter, valve control, and/orfluid access in order to provide controlled irrigation and aspirationcapabilities to the system that may be deployed through the endoscope13. These components may also be controlled using the computer system ofthe tower 30. In some embodiments, irrigation and aspirationcapabilities may be delivered directly to the endoscope 13 throughseparate cable(s).

The tower 30 may include a voltage and surge protector designed toprovide filtered and protected electrical power to the cart 11, therebyavoiding placement of a power transformer and other auxiliary powercomponents in the cart 11, resulting in a smaller, more moveable cart11.

The tower 30 may also include support equipment for the sensors deployedthroughout the robotic system 10. For example, the tower 30 may includeoptoelectronics equipment for detecting, receiving, and processing datareceived from the optical sensors or cameras throughout the roboticsystem 10. In combination with the control system, such optoelectronicsequipment may be used to generate real-time images for display in anynumber of consoles deployed throughout the system, including in thetower 30. Similarly, the tower 30 may also include an electronicsubsystem for receiving and processing signals received from deployedelectromagnetic (EM) sensors. The tower 30 may also be used to house andposition an EM field generator for detection by EM sensors in or on themedical instrument.

The tower 30 may also include a console 31 in addition to other consolesavailable in the rest of the system, e.g., console mounted on top of thecart. The console 31 may include a user interface and a display screen,such as a touchscreen, for the physician operator. Consoles in thesystem 10 are generally designed to provide both robotic controls aswell as preoperative and real-time information of the procedure, such asnavigational and localization information of the endoscope 13. When theconsole 31 is not the only console available to the physician, it may beused by a second operator, such as a nurse, to monitor the health orvitals of the patient and the operation of the system 10, as well as toprovide procedure-specific data, such as navigational and localizationinformation. In other embodiments, the console 30 is housed in a bodythat is separate from the tower 30.

The tower 30 may be coupled to the cart 11 and endoscope 13 through oneor more cables or connections (not shown). In some embodiments, thesupport functionality from the tower 30 may be provided through a singlecable to the cart 11, simplifying and de-cluttering the operating room.In other embodiments, specific functionality may be coupled in separatecabling and connections. For example, while power may be providedthrough a single power cable to the cart 11, the support for controls,optics, fluidics, and/or navigation may be provided through a separatecable.

FIG. 2 provides a detailed illustration of an embodiment of the cart 11from the cart-based robotically-enabled system shown in FIG. 1. The cart11 generally includes an elongated support structure 14 (often referredto as a “column”), a cart base 15, and a console 16 at the top of thecolumn 14. The column 14 may include one or more carriages, such as acarriage 17 (alternatively “arm support”) for supporting the deploymentof one or more robotic arms 12 (three shown in FIG. 2). The carriage 17may include individually configurable arm mounts that rotate along aperpendicular axis to adjust the base of the robotic arms 12 for betterpositioning relative to the patient. The carriage 17 also includes acarriage interface 19 that allows the carriage 17 to verticallytranslate along the column 14.

The carriage interface 19 is connected to the column 14 through slots,such as slot 20, that are positioned on opposite sides of the column 14to guide the vertical translation of the carriage 17. The slot 20contains a vertical translation interface to position and hold thecarriage 17 at various vertical heights relative to the cart base 15.Vertical translation of the carriage 17 allows the cart 11 to adjust thereach of the robotic arms 12 to meet a variety of table heights, patientsizes, and physician preferences. Similarly, the individuallyconfigurable arm mounts on the carriage 17 allow the robotic arm base 21of the robotic arms 12 to be angled in a variety of configurations.

In some embodiments, the slot 20 may be supplemented with slot coversthat are flush and parallel to the slot surface to prevent dirt andfluid ingress into the internal chambers of the column 14 and thevertical translation interface as the carriage 17 vertically translates.The slot covers may be deployed through pairs of spring spoolspositioned near the vertical top and bottom of the slot 20. The coversare coiled within the spools until deployed to extend and retract fromtheir coiled state as the carriage 17 vertically translates up and down.The spring-loading of the spools provides force to retract the coverinto a spool when the carriage 17 translates towards the spool, whilealso maintaining a tight seal when the carriage 17 translates away fromthe spool. The covers may be connected to the carriage 17 using, forexample, brackets in the carriage interface 19 to ensure properextension and retraction of the cover as the carriage 17 translates.

The column 14 may internally comprise mechanisms, such as gears andmotors, that are designed to use a vertically aligned lead screw totranslate the carriage 17 in a mechanized fashion in response to controlsignals generated in response to user inputs, e.g., inputs from theconsole 16.

The robotic arms 12 may generally comprise robotic arm bases 21 and endeffectors 22, separated by a series of linkages 23 that are connected bya series of joints 24, each joint comprising an independent actuator,each actuator comprising an independently controllable motor. Eachindependently controllable joint represents an independent degree offreedom available to the robotic arm 12. Each of the robotic arms 12 mayhave seven joints, and thus provide seven degrees of freedom. Amultitude of joints result in a multitude of degrees of freedom,allowing for “redundant” degrees of freedom. Having redundant degrees offreedom allows the robotic arms 12 to position their respective endeffectors 22 at a specific position, orientation, and trajectory inspace using different linkage positions and joint angles. This allowsfor the system to position and direct a medical instrument from adesired point in space while allowing the physician to move the armjoints into a clinically advantageous position away from the patient tocreate greater access, while avoiding arm collisions.

The cart base 15 balances the weight of the column 14, carriage 17, androbotic arms 12 over the floor. Accordingly, the cart base 15 housesheavier components, such as electronics, motors, power supply, as wellas components that either enable movement and/or immobilize the cart 11.For example, the cart base 15 includes rollable wheel-shaped casters 25that allow for the cart 11 to easily move around the room prior to aprocedure. After reaching the appropriate position, the casters 25 maybe immobilized using wheel locks to hold the cart 11 in place during theprocedure.

Positioned at the vertical end of the column 14, the console 16 allowsfor both a user interface for receiving user input and a display screen(or a dual-purpose device such as, for example, a touchscreen 26) toprovide the physician user with both preoperative and intraoperativedata. Potential preoperative data on the touchscreen 26 may includepreoperative plans, navigation and mapping data derived frompreoperative computerized tomography (CT) scans, and/or notes frompreoperative patient interviews. Intraoperative data on display mayinclude optical information provided from the tool, sensor andcoordinate information from sensors, as well as vital patientstatistics, such as respiration, heart rate, and/or pulse. The console16 may be positioned and tilted to allow a physician to access theconsole 16 from the side of the column 14 opposite the carriage 17. Fromthis position, the physician may view the console 16, robotic arms 12,and patient while operating the console 16 from behind the cart 11. Asshown, the console 16 also includes a handle 27 to assist withmaneuvering and stabilizing the cart 11.

FIG. 3 illustrates an embodiment of a robotically-enabled system 10arranged for ureteroscopy. In a ureteroscopic procedure, the cart 11 maybe positioned to deliver a ureteroscope 32, a procedure-specificendoscope designed to traverse a patient's urethra and ureter, to thelower abdominal area of the patient. In a ureteroscopy, it may bedesirable for the ureteroscope 32 to be directly aligned with thepatient's urethra to reduce friction and forces on the sensitive anatomyin the area. As shown, the cart 11 may be aligned at the foot of thetable to allow the robotic arms 12 to position the ureteroscope 32 fordirect linear access to the patient's urethra. From the foot of thetable, the robotic arms 12 may insert the ureteroscope 32 along thevirtual rail 33 directly into the patient's lower abdomen through theurethra.

After insertion into the urethra, using similar control techniques as inbronchoscopy, the ureteroscope 32 may be navigated into the bladder,ureters, and/or kidneys for diagnostic and/or therapeutic applications.For example, the ureteroscope 32 may be directed into the ureter andkidneys to break up kidney stone build up using a laser or ultrasoniclithotripsy device deployed down the working channel of the ureteroscope32. After lithotripsy is complete, the resulting stone fragments may beremoved using baskets deployed down the ureteroscope 32.

FIG. 4 illustrates an embodiment of a robotically-enabled system 10similarly arranged for a vascular procedure. In a vascular procedure,the system 10 may be configured such that the cart 11 may deliver amedical instrument 34, such as a steerable catheter, to an access pointin the femoral artery in the patient's leg. The femoral artery presentsboth a larger diameter for navigation as well as a relatively lesscircuitous and tortuous path to the patient's heart, which simplifiesnavigation. As in a ureteroscopic procedure, the cart 11 may bepositioned towards the patient's legs and lower abdomen to allow therobotic arms 12 to provide a virtual rail 35 with direct linear accessto the femoral artery access point in the patient's thigh/hip region.After insertion into the artery, the medical instrument 34 may bedirected and inserted by translating the instrument drivers 28.Alternatively, the cart may be positioned around the patient's upperabdomen in order to reach alternative vascular access points, such as,for example, the carotid and brachial arteries near the shoulder andwrist.

B. Robotic System—Table.

Embodiments of the robotically-enabled medical system may alsoincorporate the patient's table. Incorporation of the table reduces theamount of capital equipment within the operating room by removing thecart, which allows greater access to the patient. FIG. 5 illustrates anembodiment of such a robotically-enabled system arranged for abronchoscopic procedure. System 36 includes a support structure orcolumn 37 for supporting platform 38 (shown as a “table” or “bed”) overthe floor. Much like in the cart-based systems, the end effectors of therobotic arms 39 of the system 36 comprise instrument drivers 42 that aredesigned to manipulate an elongated medical instrument, such as abronchoscope 40 in FIG. 5, through or along a virtual rail 41 formedfrom the linear alignment of the instrument drivers 42. In practice, aC-arm for providing fluoroscopic imaging may be positioned over thepatient's upper abdominal area by placing the emitter and detectoraround the table 38.

FIG. 6 provides an alternative view of the system 36 without the patientand medical instrument for discussion purposes. As shown, the column 37may include one or more carriages 43 shown as ring-shaped in the system36, from which the one or more robotic arms 39 may be based. Thecarriages 43 may translate along a vertical column interface 44 thatruns the length of the column 37 to provide different vantage pointsfrom which the robotic arms 39 may be positioned to reach the patient.The carriage(s) 43 may rotate around the column 37 using a mechanicalmotor positioned within the column 37 to allow the robotic arms 39 tohave access to multiples sides of the table 38, such as, for example,both sides of the patient. In embodiments with multiple carriages, thecarriages may be individually positioned on the column and may translateand/or rotate independently of the other carriages. While the carriages43 need not surround the column 37 or even be circular, the ring-shapeas shown facilitates rotation of the carriages 43 around the column 37while maintaining structural balance. Rotation and translation of thecarriages 43 allows the system 36 to align the medical instruments, suchas endoscopes and laparoscopes, into different access points on thepatient. In other embodiments (not shown), the system 36 can include apatient table or bed with adjustable arm supports in the form of bars orrails extending alongside it. One or more robotic arms 39 (e.g., via ashoulder with an elbow joint) can be attached to the adjustable armsupports, which can be vertically adjusted. By providing verticaladjustment, the robotic arms 39 are advantageously capable of beingstowed compactly beneath the patient table or bed, and subsequentlyraised during a procedure.

The robotic arms 39 may be mounted on the carriages 43 through a set ofarm mounts 45 comprising a series of joints that may individually rotateand/or telescopically extend to provide additional configurability tothe robotic arms 39. Additionally, the arm mounts 45 may be positionedon the carriages 43 such that, when the carriages 43 are appropriatelyrotated, the arm mounts 45 may be positioned on either the same side ofthe table 38 (as shown in FIG. 6), on opposite sides of the table 38 (asshown in FIG. 9), or on adjacent sides of the table 38 (not shown).

The column 37 structurally provides support for the table 38, and a pathfor vertical translation of the carriages 43. Internally, the column 37may be equipped with lead screws for guiding vertical translation of thecarriages, and motors to mechanize the translation of the carriages 43based the lead screws. The column 37 may also convey power and controlsignals to the carriages 43 and the robotic arms 39 mounted thereon.

The table base 46 serves a similar function as the cart base 15 in thecart 11 shown in FIG. 2, housing heavier components to balance thetable/bed 38, the column 37, the carriages 43, and the robotic arms 39.The table base 46 may also incorporate rigid casters to providestability during procedures. Deployed from the bottom of the table base46, the casters may extend in opposite directions on both sides of thebase 46 and retract when the system 36 needs to be moved.

With continued reference to FIG. 6, the system 36 may also include atower (not shown) that divides the functionality of the system 36between the table and the tower to reduce the form factor and bulk ofthe table. As in earlier disclosed embodiments, the tower may provide avariety of support functionalities to the table, such as processing,computing, and control capabilities, power, fluidics, and/or optical andsensor processing. The tower may also be movable to be positioned awayfrom the patient to improve physician access and de-clutter theoperating room. Additionally, placing components in the tower allows formore storage space in the table base 46 for potential stowage of therobotic arms 39. The tower may also include a master controller orconsole that provides both a user interface for user input, such askeyboard and/or pendant, as well as a display screen (or touchscreen)for preoperative and intraoperative information, such as real-timeimaging, navigation, and tracking information. In some embodiments, thetower may also contain holders for gas tanks to be used forinsufflation.

In some embodiments, a table base may stow and store the robotic armswhen not in use. FIG. 7 illustrates a system 47 that stows robotic armsin an embodiment of the table-based system. In the system 47, carriages48 may be vertically translated into base 49 to stow robotic arms 50,arm mounts 51, and the carriages 48 within the base 49. Base covers 52may be translated and retracted open to deploy the carriages 48, armmounts 51, and robotic arms 50 around column 53, and closed to stow toprotect them when not in use. The base covers 52 may be sealed with amembrane 54 along the edges of its opening to prevent dirt and fluidingress when closed.

FIG. 8 illustrates an embodiment of a robotically-enabled table-basedsystem configured for a ureteroscopic procedure. In a ureteroscopy, thetable 38 may include a swivel portion 55 for positioning a patientoff-angle from the column 37 and table base 46. The swivel portion 55may rotate or pivot around a pivot point (e.g., located below thepatient's head) in order to position the bottom portion of the swivelportion 55 away from the column 37. For example, the pivoting of theswivel portion 55 allows a C-arm (not shown) to be positioned over thepatient's lower abdomen without competing for space with the column (notshown) below table 38. By rotating the carriage 35 (not shown) aroundthe column 37, the robotic arms 39 may directly insert a ureteroscope 56along a virtual rail 57 into the patient's groin area to reach theurethra. In a ureteroscopy, stirrups 58 may also be fixed to the swivelportion 55 of the table 38 to support the position of the patient's legsduring the procedure and allow clear access to the patient's groin area.

In a laparoscopic procedure, through small incision(s) in the patient'sabdominal wall, minimally invasive instruments may be inserted into thepatient's anatomy. In some embodiments, the minimally invasiveinstruments comprise an elongated rigid member, such as a shaft, whichis used to access anatomy within the patient. After inflation of thepatient's abdominal cavity, the instruments may be directed to performsurgical or medical tasks, such as grasping, cutting, ablating,suturing, etc. In some embodiments, the instruments can comprise ascope, such as a laparoscope. FIG. 9 illustrates an embodiment of arobotically-enabled table-based system configured for a laparoscopicprocedure. As shown in FIG. 9, the carriages 43 of the system 36 may berotated and vertically adjusted to position pairs of the robotic arms 39on opposite sides of the table 38, such that instrument 59 may bepositioned using the arm mounts 45 to be passed through minimalincisions on both sides of the patient to reach his/her abdominalcavity.

To accommodate laparoscopic procedures, the robotically-enabled tablesystem may also tilt the platform to a desired angle. FIG. 10illustrates an embodiment of the robotically-enabled medical system withpitch or tilt adjustment. As shown in FIG. 10, the system 36 mayaccommodate tilt of the table 38 to position one portion of the table ata greater distance from the floor than the other. Additionally, the armmounts 45 may rotate to match the tilt such that the robotic arms 39maintain the same planar relationship with the table 38. To accommodatesteeper angles, the column 37 may also include telescoping portions 60that allow vertical extension of the column 37 to keep the table 38 fromtouching the floor or colliding with the table base 46.

FIG. 11 provides a detailed illustration of the interface between thetable 38 and the column 37. Pitch rotation mechanism 61 may beconfigured to alter the pitch angle of the table 38 relative to thecolumn 37 in multiple degrees of freedom. The pitch rotation mechanism61 may be enabled by the positioning of orthogonal axes 1, 2 at thecolumn-table interface, each axis actuated by a separate motor 3, 4responsive to an electrical pitch angle command. Rotation along onescrew 5 would enable tilt adjustments in one axis 1, while rotationalong the other screw 6 would enable tilt adjustments along the otheraxis 2. In some embodiments, a ball joint can be used to alter the pitchangle of the table 38 relative to the column 37 in multiple degrees offreedom.

For example, pitch adjustments are particularly useful when trying toposition the table in a Trendelenburg position, i.e., position thepatient's lower abdomen at a higher position from the floor than thepatient's upper abdomen, for lower abdominal surgery. The Trendelenburgposition causes the patient's internal organs to slide towards his/herupper abdomen through the force of gravity, clearing out the abdominalcavity for minimally invasive tools to enter and perform lower abdominalsurgical or medical procedures, such as laparoscopic prostatectomy.

FIGS. 12 and 13 illustrate isometric and end views of an alternativeembodiment of a table-based surgical robotics system 100. The surgicalrobotics system 100 includes one or more adjustable arm supports 105that can be configured to support one or more robotic arms (see, forexample, FIG. 14) relative to a table 101. In the illustratedembodiment, a single adjustable arm support 105 is shown, though anadditional arm support can be provided on an opposite side of the table101. The adjustable arm support 105 can be configured so that it canmove relative to the table 101 to adjust and/or vary the position of theadjustable arm support 105 and/or any robotic arms mounted theretorelative to the table 101. For example, the adjustable arm support 105may be adjusted one or more degrees of freedom relative to the table101. The adjustable arm support 105 provides high versatility to thesystem 100, including the ability to easily stow the one or moreadjustable arm supports 105 and any robotics arms attached theretobeneath the table 101. The adjustable arm support 105 can be elevatedfrom the stowed position to a position below an upper surface of thetable 101. In other embodiments, the adjustable arm support 105 can beelevated from the stowed position to a position above an upper surfaceof the table 101.

The adjustable arm support 105 can provide several degrees of freedom,including lift, lateral translation, tilt, etc. In the illustratedembodiment of FIGS. 12 and 13, the arm support 105 is configured withfour degrees of freedom, which are illustrated with arrows in FIG. 12. Afirst degree of freedom allows for adjustment of the adjustable armsupport 105 in the z-direction (“Z-lift”). For example, the adjustablearm support 105 can include a carriage 109 configured to move up or downalong or relative to a column 102 supporting the table 101. A seconddegree of freedom can allow the adjustable arm support 105 to tilt. Forexample, the adjustable arm support 105 can include a rotary joint,which can allow the adjustable arm support 105 to be aligned with thebed in a Trendelenburg position. A third degree of freedom can allow theadjustable arm support 105 to “pivot up,” which can be used to adjust adistance between a side of the table 101 and the adjustable arm support105. A fourth degree of freedom can permit translation of the adjustablearm support 105 along a longitudinal length of the table.

The surgical robotics system 100 in FIGS. 12 and 13 can comprise a tablesupported by a column 102 that is mounted to a base 103. The base 103and the column 102 support the table 101 relative to a support surface.A floor axis 131 and a support axis 133 are shown in FIG. 13.

The adjustable arm support 105 can be mounted to the column 102. Inother embodiments, the arm support 105 can be mounted to the table 101or base 103. The adjustable arm support 105 can include a carriage 109,a bar or rail connector 111 and a bar or rail 107. In some embodiments,one or more robotic arms mounted to the rail 107 can translate and moverelative to one another.

The carriage 109 can be attached to the column 102 by a first joint 113,which allows the carriage 109 to move relative to the column 102 (e.g.,such as up and down a first or vertical axis 123). The first joint 113can provide the first degree of freedom (“Z-lift”) to the adjustable armsupport 105. The adjustable arm support 105 can include a second joint115, which provides the second degree of freedom (tilt) for theadjustable arm support 105. The adjustable arm support 105 can include athird joint 117, which can provide the third degree of freedom (“pivotup”) for the adjustable arm support 105. An additional joint 119 (shownin FIG. 13) can be provided that mechanically constrains the third joint117 to maintain an orientation of the rail 107 as the rail connector 111is rotated about a third axis 127. The adjustable arm support 105 caninclude a fourth joint 121, which can provide a fourth degree of freedom(translation) for the adjustable arm support 105 along a fourth axis129.

FIG. 14 illustrates an end view of the surgical robotics system 140Awith two adjustable arm supports 105A, 105B mounted on opposite sides ofa table 101. A first robotic arm 142A is attached to the bar or rail107A of the first adjustable arm support 105B. The first robotic arm142A includes a base 144A attached to the rail 107A. The distal end ofthe first robotic arm 142A includes an instrument drive mechanism 146Athat can attach to one or more robotic medical instruments or tools.Similarly, the second robotic arm 142B includes a base 144B attached tothe rail 107B. The distal end of the second robotic arm 142B includes aninstrument drive mechanism 146B. The instrument drive mechanism 146B canbe configured to attach to one or more robotic medical instruments ortools.

In some embodiments, one or more of the robotic arms 142A, 142Bcomprises an arm with seven or more degrees of freedom. In someembodiments, one or more of the robotic arms 142A, 142B can includeeight degrees of freedom, including an insertion axis (1-degree offreedom including insertion), a wrist (3-degrees of freedom includingwrist pitch, yaw and roll), an elbow (1-degree of freedom includingelbow pitch), a shoulder (2-degrees of freedom including shoulder pitchand yaw), and base 144A, 144B (1-degree of freedom includingtranslation). In some embodiments, the insertion degree of freedom canbe provided by the robotic arm 142A, 142B, while in other embodiments,the instrument itself provides insertion via an instrument-basedinsertion architecture.

C. Instrument Driver & Interface.

The end effectors of the system's robotic arms may comprise (i) aninstrument driver (alternatively referred to as “instrument drivemechanism” or “instrument device manipulator”) that incorporateselectro-mechanical means for actuating the medical instrument and (ii) aremovable or detachable medical instrument, which may be devoid of anyelectro-mechanical components, such as motors. This dichotomy may bedriven by the need to sterilize medical instruments used in medicalprocedures, and the inability to adequately sterilize expensive capitalequipment due to their intricate mechanical assemblies and sensitiveelectronics. Accordingly, the medical instruments may be designed to bedetached, removed, and interchanged from the instrument driver (and thusthe system) for individual sterilization or disposal by the physician orthe physician's staff. In contrast, the instrument drivers need not bechanged or sterilized, and may be draped for protection.

FIG. 15 illustrates an example instrument driver. Positioned at thedistal end of a robotic arm, instrument driver 62 comprises one or moredrive units 63 arranged with parallel axes to provide controlled torqueto a medical instrument via drive shafts 64. Each drive unit 63comprises an individual drive shaft 64 for interacting with theinstrument, a gear head 65 for converting the motor shaft rotation to adesired torque, a motor 66 for generating the drive torque, an encoder67 to measure the speed of the motor shaft and provide feedback to thecontrol circuitry, and control circuitry 68 for receiving controlsignals and actuating the drive unit. Each drive unit 63 beingindependently controlled and motorized, the instrument driver 62 mayprovide multiple (e.g., four as shown in FIG. 15) independent driveoutputs to the medical instrument. In operation, the control circuitry68 would receive a control signal, transmit a motor signal to the motor66, compare the resulting motor speed as measured by the encoder 67 withthe desired speed, and modulate the motor signal to generate the desiredtorque.

For procedures that require a sterile environment, the robotic systemmay incorporate a drive interface, such as a sterile adapter connectedto a sterile drape, that sits between the instrument driver and themedical instrument. The chief purpose of the sterile adapter is totransfer angular motion from the drive shafts of the instrument driverto the drive inputs of the instrument while maintaining physicalseparation, and thus sterility, between the drive shafts and driveinputs. Accordingly, an example sterile adapter may comprise a series ofrotational inputs and outputs intended to be mated with the drive shaftsof the instrument driver and drive inputs on the instrument. Connectedto the sterile adapter, the sterile drape, comprised of a thin, flexiblematerial such as transparent or translucent plastic, is designed tocover the capital equipment, such as the instrument driver, robotic arm,and cart (in a cart-based system) or table (in a table-based system).Use of the drape would allow the capital equipment to be positionedproximate to the patient while still being located in an area notrequiring sterilization (i.e., non-sterile field). On the other side ofthe sterile drape, the medical instrument may interface with the patientin an area requiring sterilization (i.e., sterile field).

D. Medical Instrument.

FIG. 16 illustrates an example medical instrument with a pairedinstrument driver. Like other instruments designed for use with arobotic system, medical instrument 70 comprises an elongated shaft 71(or elongate body) and an instrument base 72. The instrument base 72,also referred to as an “instrument handle” due to its intended designfor manual interaction by the physician, may generally compriserotatable drive inputs 73, e.g., receptacles, pulleys or spools, thatare designed to be mated with drive outputs 74 that extend through adrive interface on instrument driver 75 at the distal end of robotic arm76. When physically connected, latched, and/or coupled, the mated driveinputs 73 of the instrument base 72 may share axes of rotation with thedrive outputs 74 in the instrument driver 75 to allow the transfer oftorque from the drive outputs 74 to the drive inputs 73. In someembodiments, the drive outputs 74 may comprise splines that are designedto mate with receptacles on the drive inputs 73.

The elongated shaft 71 is designed to be delivered through either ananatomical opening or lumen, e.g., as in endoscopy, or a minimallyinvasive incision, e.g., as in laparoscopy. The elongated shaft 71 maybe either flexible (e.g., having properties similar to an endoscope) orrigid (e.g., having properties similar to a laparoscope) or contain acustomized combination of both flexible and rigid portions. Whendesigned for laparoscopy, the distal end of a rigid elongated shaft maybe connected to an end effector extending from a jointed wrist formedfrom a clevis with at least one degree of freedom and a surgical tool ormedical instrument, such as, for example, a grasper or scissors, thatmay be actuated based on force from the tendons as the drive inputsrotate in response to torque received from the drive outputs 74 of theinstrument driver 75. When designed for endoscopy, the distal end of aflexible elongated shaft may include a steerable or controllable bendingsection that may be articulated and bent based on torque received fromthe drive outputs 74 of the instrument driver 75.

Torque from the instrument driver 75 is transmitted down the elongatedshaft 71 using tendons along the elongated shaft 71. These individualtendons, such as pull wires, may be individually anchored to individualdrive inputs 73 within the instrument handle 72. From the handle 72, thetendons are directed down one or more pull lumens along the elongatedshaft 71 and anchored at the distal portion of the elongated shaft 71,or in the wrist at the distal portion of the elongated shaft. During asurgical procedure, such as a laparoscopic, endoscopic or hybridprocedure, these tendons may be coupled to a distally mounted endeffector, such as a wrist, grasper, or scissor. Under such anarrangement, torque exerted on drive inputs 73 would transfer tension tothe tendon, thereby causing the end effector to actuate in some way. Insome embodiments, during a surgical procedure, the tendon may cause ajoint to rotate about an axis, thereby causing the end effector to movein one direction or another. Alternatively, the tendon may be connectedto one or more jaws of a grasper at the distal end of the elongatedshaft 71, where tension from the tendon causes the grasper to close.

In endoscopy, the tendons may be coupled to a bending or articulatingsection positioned along the elongated shaft 71 (e.g., at the distalend) via adhesive, control ring, or other mechanical fixation. Whenfixedly attached to the distal end of a bending section, torque exertedon the drive inputs 73 would be transmitted down the tendons, causingthe softer, bending section (sometimes referred to as the articulablesection or region) to bend or articulate. Along the non-bendingsections, it may be advantageous to spiral or helix the individual pulllumens that direct the individual tendons along (or inside) the walls ofthe endoscope shaft to balance the radial forces that result fromtension in the pull wires. The angle of the spiraling and/or spacingtherebetween may be altered or engineered for specific purposes, whereintighter spiraling exhibits lesser shaft compression under load forces,while lower amounts of spiraling results in greater shaft compressionunder load forces, but limits bending. On the other end of the spectrum,the pull lumens may be directed parallel to the longitudinal axis of theelongated shaft 71 to allow for controlled articulation in the desiredbending or articulable sections.

In endoscopy, the elongated shaft 71 houses a number of components toassist with the robotic procedure. The shaft 71 may comprise a workingchannel for deploying surgical tools (or medical instruments),irrigation, and/or aspiration to the operative region at the distal endof the shaft 71. The shaft 71 may also accommodate wires and/or opticalfibers to transfer signals to/from an optical assembly at the distaltip, which may include an optical camera. The shaft 71 may alsoaccommodate optical fibers to carry light from proximally-located lightsources, such as light emitting diodes, to the distal end of the shaft71.

At the distal end of the instrument 70, the distal tip may also comprisethe opening of a working channel for delivering tools for diagnosticand/or therapy, irrigation, and aspiration to an operative site. Thedistal tip may also include a port for a camera, such as a fiberscope ora digital camera, to capture images of an internal anatomical space.Relatedly, the distal tip may also include ports for light sources forilluminating the anatomical space when using the camera.

In the example of FIG. 16, the drive shaft axes, and thus the driveinput axes, are orthogonal to the axis of the elongated shaft 71. Thisarrangement, however, complicates roll capabilities for the elongatedshaft 71. Rolling the elongated shaft 71 along its axis while keepingthe drive inputs 73 static results in undesirable tangling of thetendons as they extend off the drive inputs 73 and enter pull lumenswithin the elongated shaft 71. The resulting entanglement of suchtendons may disrupt any control algorithms intended to predict movementof the flexible elongated shaft 71 during an endoscopic procedure.

FIG. 17 illustrates an alternative design for an instrument driver andinstrument where the axes of the drive units are parallel to the axis ofthe elongated shaft of the instrument. As shown, a circular instrumentdriver 80 comprises four drive units with their drive outputs 81 alignedin parallel at the end of a robotic arm 82. The drive units, and theirrespective drive outputs 81, are housed in a rotational assembly 83 ofthe instrument driver 80 that is driven by one of the drive units withinthe assembly 83. In response to torque provided by the rotational driveunit, the rotational assembly 83 rotates along a circular bearing thatconnects the rotational assembly 83 to the non-rotational portion 84 ofthe instrument driver 80. Power and controls signals may be communicatedfrom the non-rotational portion 84 of the instrument driver 80 to therotational assembly 83 through electrical contacts that may bemaintained through rotation by a brushed slip ring connection (notshown). In other embodiments, the rotational assembly 83 may beresponsive to a separate drive unit that is integrated into thenon-rotatable portion 84, and thus not in parallel to the other driveunits. The rotational mechanism 83 allows the instrument driver 80 torotate the drive units, and their respective drive outputs 81, as asingle unit around an instrument driver axis 85.

Like earlier disclosed embodiments, an instrument 86 may comprise anelongated shaft portion 88 and an instrument base 87 (shown with atransparent external skin for discussion purposes) comprising aplurality of drive inputs 89 (such as receptacles, pulleys, and spools)that are configured to receive the drive outputs 81 in the instrumentdriver 80. Unlike prior disclosed embodiments, the instrument shaft 88extends from the center of the instrument base 87 with an axissubstantially parallel to the axes of the drive inputs 89, rather thanorthogonal as in the design of FIG. 16.

When coupled to the rotational assembly 83 of the instrument driver 80,the medical instrument 86, comprising instrument base 87 and instrumentshaft 88, rotates in combination with the rotational assembly 83 aboutthe instrument driver axis 85. Since the instrument shaft 88 ispositioned at the center of instrument base 87, the instrument shaft 88is coaxial with instrument driver axis 85 when attached. Thus, rotationof the rotational assembly 83 causes the instrument shaft 88 to rotateabout its own longitudinal axis. Moreover, as the instrument base 87rotates with the instrument shaft 88, any tendons connected to the driveinputs 89 in the instrument base 87 are not tangled during rotation.Accordingly, the parallelism of the axes of the drive outputs 81, driveinputs 89, and instrument shaft 88 allows for the shaft rotation withouttangling any control tendons.

FIG. 18 illustrates an instrument having an instrument based insertionarchitecture in accordance with some embodiments. The instrument 150 canbe coupled to any of the instrument drivers discussed above. Theinstrument 150 comprises an elongated shaft 152, an end effector 162connected to the shaft 152, and a handle 170 coupled to the shaft 152.The elongated shaft 152 comprises a tubular member having a proximalportion 154 and a distal portion 156. The elongated shaft 152 comprisesone or more channels or grooves 158 along its outer surface. The grooves158 are configured to receive one or more wires or cables 180therethrough. One or more cables 180 thus run along an outer surface ofthe elongated shaft 152. In other embodiments, cables 180 can also runthrough the elongated shaft 152. Manipulation of the one or more cables180 (e.g., via an instrument driver) results in actuation of the endeffector 162.

The instrument handle 170, which may also be referred to as aninstrument base, may generally comprise an attachment interface 172having one or more mechanical inputs 174, e.g., receptacles, pulleys orspools, that are designed to be reciprocally mated with one or moretorque couplers on an attachment surface of an instrument driver.

In some embodiments, the instrument 150 comprises a series of pulleys orcables that enable the elongated shaft 152 to translate relative to thehandle 170. In other words, the instrument 150 itself comprises aninstrument-based insertion architecture that accommodates insertion ofthe instrument, thereby minimizing the reliance on a robot arm toprovide insertion of the instrument 150. In other embodiments, a roboticarm can be largely responsible for instrument insertion.

E. Controller.

Any of the robotic systems described herein can include an input deviceor controller for manipulating an instrument attached to a robotic arm.In some embodiments, the controller can be coupled (e.g.,communicatively, electronically, electrically, wirelessly and/ormechanically) with an instrument such that manipulation of thecontroller causes a corresponding manipulation of the instrument e.g.,via master slave control.

FIG. 19 is a perspective view of an embodiment of a controller 182. Inthe present embodiment, the controller 182 comprises a hybrid controllerthat can have both impedance and admittance control. In otherembodiments, the controller 182 can utilize just impedance or passivecontrol. In other embodiments, the controller 182 can utilize justadmittance control. By being a hybrid controller, the controller 182advantageously can have a lower perceived inertia while in use.

In the illustrated embodiment, the controller 182 is configured to allowmanipulation of two medical instruments, and includes two handles 184.Each of the handles 184 is connected to a gimbal 186. Each gimbal 186 isconnected to a positioning platform 188.

As shown in FIG. 19, each positioning platform 188 includes a SCARA arm(selective compliance assembly robot arm) 198 coupled to a column 194 bya prismatic joint 196. The prismatic joints 196 are configured totranslate along the column 194 (e.g., along rails 197) to allow each ofthe handles 184 to be translated in the z-direction, providing a firstdegree of freedom. The SCARA arm 198 is configured to allow motion ofthe handle 184 in an x-y plane, providing two additional degrees offreedom.

In some embodiments, one or more load cells are positioned in thecontroller. For example, in some embodiments, a load cell (not shown) ispositioned in the body of each of the gimbals 186. By providing a loadcell, portions of the controller 182 are capable of operating underadmittance control, thereby advantageously reducing the perceivedinertia of the controller while in use. In some embodiments, thepositioning platform 188 is configured for admittance control, while thegimbal 186 is configured for impedance control. In other embodiments,the gimbal 186 is configured for admittance control, while thepositioning platform 188 is configured for impedance control.Accordingly, for some embodiments, the translational or positionaldegrees of freedom of the positioning platform 188 can rely onadmittance control, while the rotational degrees of freedom of thegimbal 186 rely on impedance control.

F. Navigation and Control.

Traditional endoscopy may involve the use of fluoroscopy (e.g., as maybe delivered through a C-arm) and other forms of radiation-based imagingmodalities to provide endoluminal guidance to an operator physician. Incontrast, the robotic systems contemplated by this disclosure canprovide for non-radiation-based navigational and localization means toreduce physician exposure to radiation and reduce the amount ofequipment within the operating room. As used herein, the term“localization” may refer to determining and/or monitoring the positionof objects in a reference coordinate system. Technologies such aspreoperative mapping, computer vision, real-time EM tracking, and robotcommand data may be used individually or in combination to achieve aradiation-free operating environment. In other cases, whereradiation-based imaging modalities are still used, the preoperativemapping, computer vision, real-time EM tracking, and robot command datamay be used individually or in combination to improve upon theinformation obtained solely through radiation-based imaging modalities.

FIG. 20 is a block diagram illustrating a localization system 90 thatestimates a location of one or more elements of the robotic system, suchas the location of the instrument, in accordance to an exampleembodiment. The localization system 90 may be a set of one or morecomputer devices configured to execute one or more instructions. Thecomputer devices may be embodied by a processor (or processors) andcomputer-readable memory in one or more components discussed above. Byway of example and not limitation, the computer devices may be in thetower 30 shown in FIG. 1, the cart 11 shown in FIGS. 1-4, the beds shownin FIGS. 5-14, etc.

As shown in FIG. 20, the localization system 90 may include alocalization module 95 that processes input data 91-94 to generatelocation data 96 for the distal tip of a medical instrument. Thelocation data 96 may be data or logic that represents a location and/ororientation of the distal end of the instrument relative to a frame ofreference. The frame of reference can be a frame of reference relativeto the anatomy of the patient or to a known object, such as an EM fieldgenerator (see discussion below for the EM field generator).

The various input data 91-94 are now described in greater detail.Preoperative mapping may be accomplished through the use of thecollection of low dose CT scans. Preoperative CT scans are reconstructedinto three-dimensional images, which are visualized, e.g. as “slices” ofa cutaway view of the patient's internal anatomy. When analyzed in theaggregate, image-based models for anatomical cavities, spaces andstructures of the patient's anatomy, such as a patient lung network, maybe generated. Techniques such as center-line geometry may be determinedand approximated from the CT images to develop a three-dimensionalvolume of the patient's anatomy, referred to as model data 91 (alsoreferred to as “preoperative model data” when generated using onlypreoperative CT scans). The use of center-line geometry is discussed inU.S. patent application Ser. No. 14/523,760, the contents of which areherein incorporated in its entirety. Network topological models may alsobe derived from the CT-images, and are particularly appropriate forbronchoscopy.

In some embodiments, the instrument may be equipped with a camera toprovide vision data (or image data) 92. The localization module 95 mayprocess the vision data 92 to enable one or more vision-based (orimage-based) location tracking modules or features. For example, thepreoperative model data 91 may be used in conjunction with the visiondata 92 to enable computer vision-based tracking of the medicalinstrument (e.g., an endoscope or an instrument advance through aworking channel of the endoscope). For example, using the preoperativemodel data 91, the robotic system may generate a library of expectedendoscopic images from the model based on the expected path of travel ofthe endoscope, each image linked to a location within the model.Intraoperatively, this library may be referenced by the robotic systemin order to compare real-time images captured at the camera (e.g., acamera at a distal end of the endoscope) to those in the image libraryto assist localization.

Other computer vision-based tracking techniques use feature tracking todetermine motion of the camera, and thus the endoscope. Some features ofthe localization module 95 may identify circular geometries in thepreoperative model data 91 that correspond to anatomical lumens andtrack the change of those geometries to determine which anatomical lumenwas selected, as well as the relative rotational and/or translationalmotion of the camera. Use of a topological map may further enhancevision-based algorithms or techniques.

Optical flow, another computer vision-based technique, may analyze thedisplacement and translation of image pixels in a video sequence in thevision data 92 to infer camera movement. Examples of optical flowtechniques may include motion detection, object segmentationcalculations, luminance, motion compensated encoding, stereo disparitymeasurement, etc. Through the comparison of multiple frames overmultiple iterations, movement and location of the camera (and thus theendoscope) may be determined.

The localization module 95 may use real-time EM tracking to generate areal-time location of the endoscope in a global coordinate system thatmay be registered to the patient's anatomy, represented by thepreoperative model. In EM tracking, an EM sensor (or tracker) comprisingone or more sensor coils embedded in one or more locations andorientations in a medical instrument (e.g., an endoscopic tool) measuresthe variation in the EM field created by one or more static EM fieldgenerators positioned at a known location. The location informationdetected by the EM sensors is stored as EM data 93. The EM fieldgenerator (or transmitter), may be placed close to the patient to createa low intensity magnetic field that the embedded sensor may detect. Themagnetic field induces small currents in the sensor coils of the EMsensor, which may be analyzed to determine the distance and anglebetween the EM sensor and the EM field generator. These distances andorientations may be intraoperatively “registered” to the patient anatomy(e.g., the preoperative model) in order to determine the geometrictransformation that aligns a single location in the coordinate systemwith a position in the preoperative model of the patient's anatomy. Onceregistered, an embedded EM tracker in one or more positions of themedical instrument (e.g., the distal tip of an endoscope) may providereal-time indications of the progression of the medical instrumentthrough the patient's anatomy.

Robotic command and kinematics data 94 may also be used by thelocalization module 95 to provide localization data 96 for the roboticsystem. Device pitch and yaw resulting from articulation commands may bedetermined during preoperative calibration. Intraoperatively, thesecalibration measurements may be used in combination with known insertiondepth information to estimate the position of the instrument.Alternatively, these calculations may be analyzed in combination withEM, vision, and/or topological modeling to estimate the position of themedical instrument within the network.

As FIG. 20 shows, a number of other input data can be used by thelocalization module 95. For example, although not shown in FIG. 20, aninstrument utilizing shape-sensing fiber can provide shape data that thelocalization module 95 can use to determine the location and shape ofthe instrument.

The localization module 95 may use the input data 91-94 incombination(s). In some cases, such a combination may use aprobabilistic approach where the localization module 95 assigns aconfidence weight to the location determined from each of the input data91-94. Thus, where the EM data may not be reliable (as may be the casewhere there is EM interference) the confidence of the locationdetermined by the EM data 93 can be decrease and the localization module95 may rely more heavily on the vision data 92 and/or the roboticcommand and kinematics data 94.

As discussed above, the robotic systems discussed herein may be designedto incorporate a combination of one or more of the technologies above.The robotic system's computer-based control system, based in the tower,bed and/or cart, may store computer program instructions, for example,within a non-transitory computer-readable storage medium such as apersistent magnetic storage drive, solid state drive, or the like, that,upon execution, cause the system to receive and analyze sensor data anduser commands, generate control signals throughout the system, anddisplay the navigational and localization data, such as the position ofthe instrument within the global coordinate system, anatomical map, etc.

2. Clip-Applier and Clips.

Embodiments of the disclosure relate to systems and techniques forapplying clips to ligate tissue. Medical clips can be used in a varietyof different medical procedures, including, for example, laparoscopicprocedures in which the medical clips may be used to ligate and/or sealtissue to stop bleeding. The use of clips to ligate tissue can beadvantageous as they can be faster than the use of sutures to ligatetissue. When used as part of a robotic system, it can be desirable toprovide a one or more of degrees of freedom (DOF) of movement at anarticulating wrist of the medical clip applier. It can also be desirablefor the clip applier to multi-fire wherein multiple clips are preloadedinto the instrument. Multiple clips applied from a single instrumentallows multiple clips to quickly be applied in succession while keepingthe applier at the target tissue, without reloading the applier.Embodiments of the disclosure herein relate to the use of medical clipsas part of a robotic system and in certain embodiments, the roboticsystem can provide one or more of degrees of freedom (DOF) of movementat an articulating wrist of an end effector that is configured to applyone or more medical clips. Certain embodiments can be configured with anend effector that includes multiple clips that are preloaded into acartridge such that the a plurality of clips can be delivered. Multipleclips applied from a single end effector can allow multiple clips toquickly be applied in succession while keeping the effector at thetarget tissue, without having to reload. Such an instrument that candeliver multiple clips in succession can be referred to as a multi-fireclip applier. Advantageously, in some embodiments, the multi-fire clipcan deliver a multitude of clips in succession without having to reloadthe clips.

There are a number of challenges in providing a robotically controlledmulti-fire clip applier. As it is desired to reduce the size ofincisions formed in a patient, instruments are becoming increasinglysmaller in size. Robotic instruments incorporate a number of pulleys andcables, thereby reducing the overall available space within theinstruments. As these instruments increase their number of DOFs (e.g.,from a single DOF wrist to a multi-DOF wrist), thereby increasing thecomplexity of the pulleys and cables within the instruments, these sizeconstraints are exacerbated.

One example of a surgery that can apply a multi-fire clip applier is acolon resection, wherein a portion of a colon is removed. In such aprocedure, a multi-fire clip end effector can apply first and secondclips on one side of a colon portion to be resection, and a third clipon another side of the colon portion to be resected. The first andsecond clips can be applied to the high-pressure side. Tissue may be cutin the space between the second and third clips.

Another example of a surgery that can apply a multi-fire clip applier isa laparoscopic cholecystectomy, wherein a gall bladder of a patient isremoved. In such a procedure, a multi-fire clip applier can apply firstand second clips on one side of a cystic duct away from the gall bladdernear the common bile duct, and a third clip on another side of thecystic duct nearer the gall bladder. The cystic duct may be cut in thespace between the second and third clips. The gall bladder may beremoved with the first and second clips providing redundant ligationsecurity on the cystic duct near the common bile duct, while the thirdclip near the gall bladder keeps bile and stones from disgorging duringthe removal of the gall bladder.

FIG. 21 illustrates an example embodiment of a medical instrument 200 inaccordance with aspects of this disclosure. In the embodimentillustrated in FIG. 21, the medical instrument 200 can be arobotically-controlled surgical instrument that can include a shaft 205,a handle 210, and an end effector 215. The instrument 200 can be coupledto any of the instrument drivers discussed above. One or more cables(not illustrated) can run along an outer surface of the shaft 205 and/orone or more cables can also run through the elongated shaft 205.Manipulation of the one or more cables (e.g., via an instrument driver)results in actuation of the end effector 215.

The handle 210, which may also be referred to as an instrument base, maygenerally include an attachment interface having one or more mechanicalinputs, e.g., receptacles, pulleys or spools, that are designed to bereciprocally mated with one or more torque couplers on an attachmentsurface of an instrument driver.

Depending on the implementation of the particular instrument 200, theend effector 215 may be embodied to perform one or more differentmedical and/or surgical tasks, which can be effectuated via tensioningthe one or more cables. In some embodiments, the instrument 200comprises a series of pulleys to which the one or more cables can beoperatively coupled that enable the shaft 205 to translate relative tothe handle 210.

In some embodiments, the instrument 200 may include an end effector 215that is adapted to apply one or more clips adapted to grip and to closeonto tissue, and in certain embodiments the end effector 216 is coupledto a wrist providing at least one degree of freedom of movement.

FIGS. 22A-22D illustrate an example embodiment of a novel clip 300 to befired from a clip applier, as discussed above. FIGS. 22A and 22Billustrate front perspective views of the clip 300. FIGS. 22C and 23Dillustrate side perspective views of the clip 300. FIGS. 22A and 22Cillustrate the clip 300 in an open position. FIGS. 22B and 22Dillustrate the clip 300 in a closed position.

The clip 300 can include a first arm 320 and a second arm 330. Aproximal end of the first arm 320 and a proximal end of the second arm330 can be joined to form a vertex 310. The vertex 310 may include oneor more loops 312. The loops 312 of the vertex 310 may form a spring,such as a torsion spring formed by the one or more loops or coils. Thespring may be biased to bias the first arm 320 and second arm 330towards each other in the closed position. The clip 300 may use thespring to assist with the automatic closing. The use of at least onecomplete loop 312 at the vertex 310 also advantageously prevents any gapor unclamped area between the first arm 320 and second arm 330 when theclip 300 is in the closed position. Therefore, when the clip 300 isclosed on tissue, the tissue received in the clip 300 is fully ligated.Advantageously, the illustrated embodiment of the clip 300 can create anoverlap between first arm 320 and second arm 330 that result in no gapnear the vertex 310.

As shown in FIGS. 22A and 22B, the first arm 320 can be formed of asingle strut 322 while the second arm 330 can be formed by a pair ofstruts including a second strut 332 and a third strut 334. The distalend of the first strut 322 of the first arm 320 may form a first loop340. The distal ends of the second strut 332 and the third strut 334 ofthe second arm 330 may meet to form a second loop 350. The first loop340 may be smaller in diameter than the second loop 350 such that thefirst loop 340 can fit within the second loop 350 as shown in FIG. 22B.In other embodiments, the distal end of the first arm 320 may form afirst tab (not shown) and the distal end of the second arm 330 may forma second tab (not shown) that can abut against each other in a closedposition. In some embodiments, the first strut 322 can overlap and crossbeyond the second and third struts 332, 334 in the closed configuration.In other words, in a closed configuration, first strut 322 canadvantageously pass slightly beyond a plane formed by second and thirdstruts 332, 334. This overlap advantageously helps to ensure that avessel/lumen/duct/tissue that is clipped by a clip will not leak.

The first loop 340 may be aligned with the length of the first strut322. The length of the first loop 340 may also be aligned with an axisnot parallel to the length of the first strut 322. Similarly, the lengthof the second loop 350 may aligned with an axis not parallel to thelength of the second and third struts 332, 334. For example, the lengthof the first loop 340 and length of the second loop may be configured tobe parallel with each other when the clip 300 is in a fully openposition, as shown in FIG. 22A. Similarly, the length of the first loop340 and the length of the second loop 350 can be configured to form anacute angle when the clip 300 is in the closed position, as shown inFIG. 22D.

In the open position, the distal end of the first arm 320 and the distalend of the second arm 330 are separated from each other. In the openposition, such as shown in FIGS. 22A and 22C, the first loop 340 of thefirst arm 320 and the second loop 350 of the second arm 330 areseparated from each other. In the closed position, such as shown inFIGS. 22B and 22D, the distal end of the first arm 320 and the distalend of the second arm 330 are intermeshed with each other. In the closedposition, the first loop 340 of the first arm 320 and the second loop350 of the second arm 330 are intermeshed with each other. In someembodiments, the first loop 340 may be received within the second loop350 when the clip 300 is in the closed position. In particular, this isseen in FIG. 22D, where the first loop 340 extends past the second loop350. In some embodiments, the single strut 322 of the first arm 320 maybe received between the pair of struts 332, 334 of the second arm 330when the clip 300 is in the closed position. As shown in FIG. 22E, thefirst arm 320 may extend past or beyond the second arm 330 in the closedposition. The clip 300 may have a center plane from the center of thevertex 310, such that each of the first arm 320 and second arm 330 areequally spaced at each point along their respective lengths from thecenter plane when the clip 300 is in the open position. The center planemay bisect the clip 300 such that each of the first arm 320 and thesecond arm 330 are equally angled from the center plane in the openposition. In the closed position, each of the first arm 320 and thesecond arm 330 pass the center plane. As described previously, the firstarm 320 may be formed by a single strut 322 and the second arm 330 canbe formed by a pair of struts, the second strut 332 and third strut 334.In the closed position, the first strut 322 may pass between and beyondthe second and third struts 332, 334. The first arm 320 and the secondarm 330 may pass beyond each other to form an angle relative to eachother.

FIG. 23 illustrates the clip 300 positioned closed on a vessel 302. Theclip 300 is configured to lock or over-close at the distal end of theclip 300 as described herein, so that the clip 300 will not slip off ofthe vessel 302. In the closed configuration, the clip 300 is designedsuch that the distal loop 340 of the first arm 320 interlocks,intermeshes, or interdigitates with the distal loop 350 of the secondarm 330. This is enabled by having the distal loop 340 of the first arm320 be of a relatively smaller size than the distal loop 350 of thesecond arm 330, thereby allowing the distal loop 340 of the first arm320 to pass through the distal loop 350 of the second arm 330. Byincluding distal portions of the arms that interlock with one another,the clip 300 provides a secure grip of a vessel 302, as shown in FIG.23.

In addition to the distal loops 340, 350 interlocking, the first arm 320is formed of one strut 322, while the second arm 330 is formed of twostruts 332, 334. Accordingly, the clip 300 uses three clamping strutsfor ligation. In this embodiment, the single strut 322 passes betweenand through two struts 332, 334. When vessel is caught between the firstand second arms 320, 330 of the clip 300, the vessel 302 is forced intoa zig-zag shape which advantageously increases ligation security.

FIGS. 24A and 24B illustrate another embodiment of a clip 400 that canbe used to ligate tissue. As shown in FIGS. 24A and 24B, the clip 400 inthe illustrated embodiment includes a first arm 420 and a second arm430. The first arm 420 and second arm 430 may each include one strut ormember 432, as shown in FIGS. 25A-25B. The first arm 420 and second arm430 may be connected or joined at one end to form a vertex 410. Aproximal end of the first arm 420 and a proximal end of the second arm430 can be joined to form the vertex 410. The vertex 410 may include oneor more loops 412. The one more loops of the vertex 410 form include aspring, such as a torsion spring. The torsion spring may be biased tobias the first arm 420 and second arm 430 towards each other in theclosed position. The clip 400 may use a multi-coil spring to assist withthe automatic closing. The clip 400 may be configured as described abovewith at least one loop 412 to advantageously prevent any gap orunclamped area between the first arm 420 and the second arm 430.

The distal end of the first arm 420 may include a first clamp 440. Thedistal end of the second arm 430 may include a second clamp 450. Thefirst clamp 440 and second clamp 450 may be configured to interlink orinterlock with each other when the clip 400 is in the closed position.The first clamp 440 and the second clamp 450 may be cup shaped or “U”shaped such that there is an open face and a closed face of each clampas well as a first side and a second side of each clamp. The first clamp440 and second clamp 450 may be oriented in opposite directions suchthat when the clip 400 is in a closed position, the open faces of thefirst clamp 440 and the second clamp 450 may interlock with each other.

The first clamp 440 may be offset from the first arm 420 in a firstdirection. For example, the first side of the first clamp 440 may beconnected to the strut 422 of the first arm 420. Similarly, the secondclamp 450 may be offset from the second arm 430 in an opposite directionfrom the first direction. For example, the second side of the secondclamp 450 may be connected to the strut 432 of the second arm 430. Withthis configuration, the first arm 420 and the second arm 430 are insecured closely together with each other when the first clamp 40 and thesecond clamp 450 are interlocked in the closed position.

FIGS. 25A-25C illustrate an embodiment of a cartridge 500 that holds anddispenses one or more clips, such as the clips 300, 400 as describedherein. The cartridge 500 may be disposable, such that the cartridge 500is intended to be thrown away after each use. The cartridge 500 may alsobe rechargeable, such that the cartridge 500 may be sterilized andreloaded with one or more clips to be reused. Additionally, somecomponents of the cartridge 500 may be disposable while others arerechargeable.

The cartridge 500 can be removably coupled to the robotic arm. Therobotic arm may include an elongate shaft (as described above) extendingbetween a proximal end and a distal end, and a wrist 600 extending fromthe distal end of the elongate shaft. The wrist 600 may be used incombination with the robotic system as described above. The wrist 600may provide at least one degree of freedom to actuate and/or dispensethe one or more clips out of the cartridge 500 along an actuation axis550 and certain embodiments the wrist 600 can provide at least onedegree of freedom of movement. In some embodiments, the wrist 600 mayprovide at least two degrees of freedom (e.g., a proximal pitch and adistal yaw) to actuate and/or dispense one or more clips out of acartridge along an actuation axis. For example, in the illustratedembodiment the wrist 600 can be configured to rotate the cartridge 500about at least a first axis and in certain embodiments also about secondaxis. An advantage of the illustrated embodiment, is that a clip and/ormultiple clips can be dispensed with only one degree of movement oractuation. By utilizing one degree of freedom of movement for dispensingthe clips, remaining cables and/or pulleys can be used to provide forone or degrees of freedom of movement.

As noted above, the wrist 600 may provide more than one degree offreedom, such as two degrees of freedom. In certain arrangements, theelongate shaft may provide one degree of freedom, such that the shaftmay be translated along the one degree of freedom, such as along aninsertion or retraction axis, such as the actuation axis 550. The wrist600 may also include one or more pulleys 650, which may receive one ormore cables capable of moving an actuator to advance one or more clipsthrough the cartridge 500. In this manner, the wrist 600 may actuatedeployment of the one or more clips from the cartridge 500, wherein theone or more clips are capable of being both delivered and automaticallyclipped by the one degree of freedom movement of the actuator.

As shown in FIG. 25A, the cartridge 500 may include a first plate 530and a second plate 540 on opposing sides of the cartridge 500, such ason the top side and bottom side. The cartridge 500 may include a firstchannel or track 510 and a second channel or track 520 on opposing sidesof the cartridge 500 as shown in FIG. 25C. The first track 510 canreceive or engage with the first loops 340 of the one or more clips 300.The second track 520 may receive or engage with the second loops 350 ofthe one or more clips 300. Advantageously, by having the tracks engagewith the loops, this helps to keep the clips open as they translatealong the cartridge. The first track 510 and second track 520 may beseparated on either side of the cartridge 500. The tracks 510, 520 maybe configured to hold each of the plurality of clips 300 in an openposition, such that the distal ends or loops of each of the clips 300are separated from each other. When each clip 300 is actuated to bepushed out of the distal end of the cartridge 500, the clip 300dispensed will snap shut in a closed position, such that the distal endsof each clip 300 are positioned close to each other, such as where thedistal ends are interlocked with each other as described above.

The one or more clips 300 may be configured to automatically shut whendispensed from the cartridge 500. As discussed herein, the clip 300 mayinclude a torsion spring where the arms of the clip 300 are biasedtowards each other in the closed position an can assist with automaticclosing. This is advantageous as other instruments may not have clipsthat are automatically shut, thereby utilizing at least two types ofactuation to both translate and shut a clip that is deployed from a clipapplier.

FIG. 26 illustrates the cartridge 500 with the second plate 540 removed.As shown in FIG. 26, the cartridge 500 may hold four clips 300 in anested configuration within the cartridge 500. The cartridge 500 mayalso include between one, two, three, four or more than four clips 300.As described previously, the first loops 340 of the clips 300 may beheld in a first channel 510 while the second loops 350 of the clips 300may be held in a second channel 520. The clips 300 may be nested suchthat the clips 300 are placed close to each other within the cartridge500. The thickness of the clips 300 can be minimized so that clips 300may be placed close together in a skeletonized area of the cartridge500. Additionally, the minimized thickness of the clips 300 can alsoadvantageously provide greater visibility for the surgeon to see aroundthe one or more clips 300. The clips 300 having a three armconfiguration where a first arm 320 having one strut 322 and a secondarm 330 having two struts 332, 334 also allows the plurality of clips300 to next closely together.

The nesting configuration allows the one or more clips to be loaded orpacked into the cartridge 500. The nesting configuration advantageouslyallow the cartridge 500 length to be reduced than if the one or moreclips were laid end to end. For example, the cartridge 500 may bereduced by 55%, 65%, 75% or more.

FIGS. 27A and 27B illustrate side views of the cartridge 500 whereinportions of the outer housing is transparent. As shown in FIG. 27A, thefirst track 510 may include a series of one or more ratchet elementssuch as tangs or prongs 514 configured to hold each clip 300 in placealong the length of the cartridge 500. The ratchet elements are alsoconfigured to only allow the clips 300 to move in one direction, andthus prevent clips from moving in a backwards direction.

The first track 510 may include ratchet elements such as a series oftangs or prongs 514. The prongs 514 may be positioned on only one sideof the first track 510, as shown on the bottom side of the first track510 in FIG. 27A. In other embodiments, the first track 510 may alsoinclude a second series of ratchet elements such as prongs 524, on theother side of the first track 510, such as the top side. The secondprongs 524 may be configured to actuate movement of the clips 300 out ofthe distal end of the cartridge 500. The second prongs 524 may besimilarly structured to the first prongs 514, to only allow a one wayratchet motion. The second prongs 524 may act as an actuator to actuatethe one or more clips along the tracks of the cartridge 500. Forexample, the second prongs 524 may be advanced by actuating a pulley, asdescribed more below. The prongs 514, 524 of the first track 510 may beconfigured to engage with the first distal loops 340 of the clips 300.Similarly, as shown in FIG. 27B, the second track 520 may include afirst series of one or more prongs or tangs 514 configured to hold eachclip 300 in place along the length of the cartridge 500. Similarly, thesecond track 520 may include a set of second prongs 524 configured toactuate movement of the clips 300 out of the distal end of the cartridge500. The prongs 514, 524 of the second track 520 may be configured toengage with the second distal loops 350 of the clips 300.

As described previously, the prongs 514, 524 may be configured toprevent the clips 300 from moving in a reverse direction or backing up.The prongs 514, 524 are oriented in a first angle and direction suchthat when each clip 300 is advanced forward (toward the distal end ofthe cartridge 500), the distal loops 340, 350 push the prongs 514, 524of the tracks 510, 520 fold down, such that the distal loops 340, 350may slide over the prongs 514, 524 of the tracks 510, 520. When thedistal loops 340, 350 of the clips 300 have advanced past the prongs514, 524, the prongs 514, 524 pop back up. The prongs 514, 524 orientedat an angle prevent the distal loops 340, 350 from sliding back in areverse direction.

The channels or tracks 510, 520 may hold the clips 300 open and in placeuntil the clip 300 is positioned at the end of each channel or track510, 520. When the first and second loops 340, 350 of the clip 300reaches the end of the tracks 510, 520, an incremental push of moves thefirst and second loops 340, 350 out of the tracks 510, 520 and the clip300 snaps closed. This incremental push may come from an actuatorpushing the first clip at one end of the cartridge 500, which in turnpushes the remainder of the plurality of clips, to push the last clippositioned at the end of the tracks 510, 520 out of the cartridge 500.The clips 300 may also be advanced through movement of the first plate530 or second plate 540. The first plate 530 or second plate 540 may beadvanced forward and backwards to advance each clip 300. For example,the second plate 540 may be actuated to move the one or more clipsforward while the first plate 530 remains static.

FIGS. 28A and 28B illustrate side views of the cartridge 500 whereinportions of the outer housing is removed. As shown in FIGS. 28A and 28B,where the first plate 530 is removed, the and second prongs 524 may beconnected or integral with the second plate 540. As shown in FIG. 28B,the pulley 650 may include a pin 655 that is received within a slot 545of the second plate 540. As the pulley 650 is actuated to rotate, thesecond plate 540 may be advanced through the connection of the pin 655received in the slot 545. The advancement of the second plate 540advances the first clip 300 out of the distal end of the cartridgethrough engagement of the second prongs 524 with the distal loops of theclip 300. While the second prongs 524 actuates the movement of the clips300, the distal loops of the clips 300 fold down and allow the distalends to move past the first prongs 514, as described previously.

The wrist 600 may include a two pulleys 650. The second pulley 650 maycontrol yaw rotation of the cartridge 500. The pulleys 650 may movesynchronously with the one pulley 650 when the cartridge 500 is beingrotated in the yaw direction. The differential movement between thepulleys 650 drives the second plate 540 forward and backward to advancethe clips 300.

3. Implementing Systems and Terminology.

Implementations disclosed herein provide systems, methods and apparatusfor clip appliers and associated clips to ligate tissue including anarticulating wrist.

It should be noted that the terms “couple,” “coupling,” “coupled” orother variations of the word couple as used herein may indicate eitheran indirect connection or a direct connection. For example, if a firstcomponent is “coupled” to a second component, the first component may beeither indirectly connected to the second component via anothercomponent or directly connected to the second component.

The functions for controlling the articulating medical instrumentsdescribed herein may be stored as one or more instructions on aprocessor-readable or computer-readable medium. The term“computer-readable medium” refers to any available medium that can beaccessed by a computer or processor. By way of example, and notlimitation, such a medium may comprise random access memory (RAM),read-only memory (ROM), electrically erasable programmable read-onlymemory (EEPROM), flash memory, compact disc read-only memory (CD-ROM) orother optical disk storage, magnetic disk storage or other magneticstorage devices, or any other medium that can be used to store desiredprogram code in the form of instructions or data structures and that canbe accessed by a computer. It should be noted that a computer-readablemedium may be tangible and non-transitory. As used herein, the term“code” may refer to software, instructions, code or data that is/areexecutable by a computing device or processor.

The methods disclosed herein comprise one or more steps or actions forachieving the described method. The method steps and/or actions may beinterchanged with one another without departing from the scope of theclaims. In other words, unless a specific order of steps or actions isrequired for proper operation of the method that is being described, theorder and/or use of specific steps and/or actions may be modifiedwithout departing from the scope of the claims.

As used herein, the term “plurality” denotes two or more. For example, aplurality of components indicates two or more components. The term“determining” encompasses a wide variety of actions and, therefore,“determining” can include calculating, computing, processing, deriving,investigating, looking up (e.g., looking up in a table, a database oranother data structure), ascertaining and the like. Also, “determining”can include receiving (e.g., receiving information), accessing (e.g.,accessing data in a memory) and the like. Also, “determining” caninclude resolving, selecting, choosing, establishing and the like.

The phrase “based on” does not mean “based only on,” unless expresslyspecified otherwise. In other words, the phrase “based on” describesboth “based only on” and “based at least on.”

The previous description of the disclosed implementations is provided toenable any person skilled in the art to make or use the presentinvention. Various modifications to these implementations will bereadily apparent to those skilled in the art, and the generic principlesdefined herein may be applied to other implementations without departingfrom the scope of the invention. For example, it will be appreciatedthat one of ordinary skill in the art will be able to employ a numbercorresponding alternative and equivalent structural details, such asequivalent ways of fastening, mounting, coupling, or engaging toolcomponents, equivalent mechanisms for producing particular actuationmotions, and equivalent mechanisms for delivering electrical energy.Thus, the present invention is not intended to be limited to theimplementations shown herein but is to be accorded the widest scopeconsistent with the principles and novel features disclosed herein.

What is claimed is:
 1. A robotically controlled surgical instrument,comprising: a plurality of clips, wherein each of the plurality of clipscomprises a first arm with a distal end, a second arm with a distal end,and a torsion spring coupling the first and second arms together attheir respective proximal ends and biasing the first and second towardeach other to a closed position; an elongate shaft extending between aproximal end and a distal end; a wrist extending from the distal end ofthe elongate shaft, the wrist providing at least one degree of freedomof movement; and an end effector extending from the wrist and moveablewith the wrist, the end effector comprising a cartridge for deliveringthe plurality of clips in succession without reloading, wherein thecartridge includes a first track and a second track, and wherein a lipof each of the first track and the second track hold each of theplurality of clips in the open position.
 2. The surgical instrument ofclaim 1, wherein the plurality of clips comprises at least four clips.3. The surgical instrument of claim 1, wherein the plurality of clipsare nested with each other within the cartridge.
 4. The surgicalinstrument of claim 3, wherein a length of the plurality of clips is atleast 50% less than if the plurality of clips were each laid end to end.5. The surgical instrument of claim 1, wherein first open ends of theplurality of clips are positioned within a first track.
 6. The surgicalinstrument of claim 1, wherein the elongate shaft is coupled to arobotic arm.
 7. The surgical instrument of claim 1, wherein the distalend of each of the first arms is positioned within the first track andthe distal end of each of the second arms is positioned within thesecond track to hold each of the plurality of clips in an open position.8. The surgical instrument of claim 7, wherein when each of theplurality of clips are expelled from the cartridge, the first and secondarm of each of the plurality of clips move towards each other to aclosed position.
 9. The surgical instrument of claim 8, wherein in theclosed position the distal end of the first arm is intermeshed with thedistal end of the second arm.
 10. The surgical instrument of claim 1,wherein each of the plurality of clips are configured to be stored inthe cartridge in an open position and be closed onto tissue in a closedposition, wherein the distal end of the first arm and the distal end ofthe second arm are separated from each other in the open position,wherein the distal end of the first arm and the distal end of the secondarm are intermeshed with each other in the closed position.
 11. Thesurgical instrument of claim 1, wherein the distal end of the first armcomprises a tab.
 12. The surgical instrument of claim 11, wherein thedistal end of the second arm comprises a loop that is larger than thetab of the first arm.
 13. The surgical instrument of claim 11, whereinthe tab of the first arm comprises a loop that is smaller than the loopof the second arm.
 14. The surgical instrument of claim 1, wherein thefirst and second arms connect together at their respective proximal endsby a loop.
 15. The surgical instrument of claim 1, wherein the first andsecond arms connect together at their respective proximal ends by aplurality of loops.
 16. The surgical instrument of claim 1, wherein theelongate shaft is capable of movement in one degree of freedom.
 17. Asurgical instrument, comprising: a plurality of clips, wherein each ofthe plurality of clips comprises a first arm with a distal end, a secondarm with a distal end, and a torsion spring coupling the first andsecond arms together at their respective proximal ends and biasing thefirst and second toward each other to a closed position; an elongateshaft extending between a proximal end and a distal end; a wristextending from the distal end of the elongate shaft; and an end effectorextending from the wrist; wherein the wrist comprises one or more cablescapable of moving an actuator with one degree of freedom of movementwithin the end effector to advance the plurality of clips through theend effector, wherein the end effector includes a first track and asecond track, a lip of each of the first track and the second track holdeach of the plurality of clips in the open position, and the pluralityof clips are capable of being both delivered and automatically clippedby the one degree of freedom movement of the actuator.
 18. The surgicalinstrument of claim 17, wherein the plurality of clips are received in acartridge.
 19. The surgical instrument of claim 18, wherein theplurality of clips move along the first and second track within thecartridge.